ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client’s risk of developing a pressure injury?
Correct Answer: C
Rationale: The correct answer is C: Ensure the client’s heels are not touching the mattress. This is important because pressure injuries commonly occur on bony prominences, such as the heels, due to prolonged pressure and friction. By ensuring the client’s heels are elevated off the mattress, the nurse can reduce the risk of pressure injury development in this area. Repositioning the client every 4 hours (choice
A) is important but may not specifically address the risk of pressure injury on the heels. Raising the head of the client’s bed to a 60° angle (choice
B) is more related to preventing aspiration in a postoperative client than preventing pressure injuries. Massaging the client’s bony prominences (choice
D) can actually increase the risk of skin breakdown due to friction and shearing forces.
Question 2 of 5
A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
Correct Answer: D
Rationale: The correct answer is D: Right lateral in Trendelenburg position. Placing the client in this position allows gravity to assist in the drainage of secretions from the left lower-lobe atelectasis. The Trendelenburg position promotes the movement of mucus towards the larger airways for easier expectoration. The other choices are incorrect because:
A) Supine in low-Fowler's position does not facilitate drainage from the lower lobes.
B) Side-lying with the right side of the chest elevated would not effectively target the left lower lobe.
C) Prone with pillows under the lower extremities is not ideal for addressing atelectasis in the lower lobes.
Question 3 of 5
A nurse is reviewing the laboratory results of a female client who has liver dysfunction and is receiving a continuous tube feeding. Which of the following findings should the nurse identify as a protein deficiency?
Correct Answer: A
Rationale: The correct answer is A: Albumin 3.1 g/dL. Albumin is the main protein in the blood and is produced by the liver. In liver dysfunction, the synthesis of albumin is decreased, leading to low levels in the blood, indicating protein deficiency. Transferrin (
B) is a protein involved in iron transport, not a direct indicator of protein deficiency. Uric acid (
C) and total iron-binding capacity (
D) are not specific markers for protein deficiency.
Question 4 of 5
A community health nurse is visiting an older adult client who recently moved into an assisted living apartment. Which of the following client statements indicates difficulty accepting their transition?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale:
Choice B indicates difficulty accepting the transition as the client is isolating themselves from social activities due to perceived differences with other residents. This can lead to feelings of loneliness and reluctance to engage with the new community. In contrast, choices A, C, and D show the client adapting positively to the new environment by acknowledging benefits, following staff advice for safety, and finding alternative transportation solutions.
Summary:
Choice B stands out as the client's statement reflects potential social withdrawal, while the other choices demonstrate acceptance and adaptation to the changes in the assisted living setting.
Question 5 of 5
A nurse is reviewing the client’s medical record. Which of the following findings places the client at risk for heart disease? (Select all that apply.)
Correct Answer: A,B,C,E,F
Rationale: The correct answer includes family history, fasting glucose level, history of hyperlipidemia, hypertension, and cholesterol level. Family history is a non-modifiable risk factor for heart disease. Elevated fasting glucose indicates potential diabetes, a risk factor for heart disease. Hyperlipidemia contributes to plaque buildup in arteries. Hypertension strains the heart and blood vessels. Abnormal cholesterol levels can lead to atherosclerosis.
Choices D and G are not directly linked to heart disease risk.